HospitalInspections.org

Based on a review of clinical records, interview with hospital personnel, and review of hospital policy, the hospital failed to ensure that two patients (#306 and #308) had comprehensive nursing assessments during the triage process. The findings include:

a. Patient #306 arrived to the Emergency Department and was triaged at 12:34 AM on 5/11/11. The triage note reflected that the patient called EMS (Emergency Medical Services) after becoming diaphoretic and short of breath at home. The note reflected that the patient stated he/she felt much better following the administration of oxygen by EMS. Review of the pain assessment completed by the triage nurse (RN #112) at 12:37 AM on 5/11/11, reflected that the patient was experiencing chest pain at a level of 10/10 (1 being the least, 10 the most) on the pain scale. The record failed to show evidence that the patient's pain was addressed and/or reported to the medical provider. During interview on 5/12/11 at approximately 10:00 AM, RN #112 stated that she took report from EMS that the patient had experienced pain prior to coming to the hospital. The nurse stated she never assessed the patient for a pain level at triage.
Review of the hospital policy for ED documentation directed that the triage nurse should assess the patient, in part, for pain level.

b. Review of Patient #308's ED record identified that the patient presented to the ED with the chief complaint of altered mental status. Review of the triage note dated 5/10/11 at 5:26 PM, failed to reflect an assessment of the patient's mental status but rather addressed an additional complaint of left arm swelling. The clinical record lacked evidence that a past medical history and pain assessment was completed.


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